Health inspection·October 31, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: Residents Affected - Few 1. Report an allegation of abuse to the State agency (Department of Public Health) within 24 hours for one of 3 sampled residents (Resident 1). This deficient practice had the potential to result in further abuse for Resident 1. Findings: During a review of Resident 1 ' s face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 1 was admitted to the facility on [DATE]. The face sheet indicated Resident 1 ' s diagnoses included dementia (a progressive state of decline in mental abilities), urinary tract infection (UTI- an infection in the bladder/urinary tract), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and cerebral infarction (when the blood supply to part of the brain is blocked or reduced). During a review of Resident 1 ' s Minimum Data Set (MDS- a federally mandated resident assessment tool), the MDS indicated Resident 1 cognitive skills (thinking skills) was moderately impaired (a physical or mental condition that significantly limits a person's ability to function in their daily life). The MDS also indicated Resident 1 required partial/moderate assistance with toileting hygiene, showering, and upper/lower body dressing. During a review of Resident 1 ' s social services notes, dated 10/25/2024, at 8:42 a.m., the social services note indicated Resident 1 was on the phone with her family member (FM 1) and stated someone tried to crawl in her bed and rape her. The social services notes indicated Resident 1 stated the person was her second cousin. The social services note indicated Resident 1 ' s FM 1, who was on the phone with the resident at the time of the allegation, stated Resident 1 was hallucinating and confused, then ended the call. During an interview, on 10/31/2024 at 12:04 p.m. with the Social Services Director (SSD), the SSD stated, the Activities Assistant (AA) informed her of Resident 1 ' s alleged abuse allegations on 10/25/2024. The SSD stated she reported the allegation to the Director of Nursing. The SSD stated the risk of failing to report abuse in a timely manner could result in placing a resident at risk for further abuse. During an interview on 10/31/2024 at 12:20 p.m. with the Activities Assistant (AA), the AA stated Page 1 of 2 055608 055608 10/31/2024 Primrose Post-Acute 515 Centinela Ave. Inglewood, CA 90302

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few while assisting Resident 1 during her phone call with her daughter on 10/25/2024, she heard Resident 1 stating to FM 1 again that a family member attempted to rape her. The AA stated she informed the SSD of Resident 1 ' s allegation. The AA stated after informing the SSD of the allegations, she went to assist other residents and did not know what happened afterwards. The AA stated the allegation was to be reported. The AA stated the risk of failing to report abuse in a timely manner could result in a resident being in danger. During an interview on 10/31/2024 at 12:37 p.m. with the Director of Nursing (DON), the DON stated the SSD had informed her of Resident 1 ' s abuse allegation. The DON stated the reason the allegation was not reported was due to Resident 1 ' s daughter claiming Resident 1 was hallucinating and confused. The DON stated the time frame for reporting abuse was within 2 hours. The DON stated the allegation should had been reported on 10/25/24 and was not. The DON stated the risk of failing to report abuse in a timely manner could result in further abuse. During an interview on 10/31/2024 at 1:04 p.m. with the Administrator (ADM), the ADM stated he was initially informed of Resident 1 ' s abuse allegation on 10/30/24. The ADM stated the allegation from 10/25/2024 was not reported. The ADM stated the risk of failing to report abuse in a timely manner could result in putting residents ' in the way of unnecessary harm. During a review of the facility ' s policy and procedures, titled Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, dated, the policy indicated 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. and ' Immediately ' is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 055608 Page 2 of 2